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The Summer of Wellness’s Discontent

The series of unflatteringarticles published in Health Affairs early this year – the first unfavorable press wellness had ever received in a top tier policy journal — turned out to be a harbinger of what became the wellness industry’s summer of discontent. Perhaps in error, the Journal of Occupational and Environmental Medicine (JOEM) also drifted into the sea of credibility on wellness early in 2013 by publishing a meta-analysis of the industry’s claims of economic success.

The analysis, by researchers at Tufts, destroys the industry mythology of respectability by noting that out of over 2,000 papers published in the world’s medical literature, only 10 (0.5%) are worth discussing and that discussion leads essentially nowhere. Not surprisingly, like our essays here and in Health Affairs, the Tufts work has been universally ignored by the wellness true believers.

Starting with those articles, and especially over the last four months, those true believers have lost control of the dialog — starting right here with THCB, which gets credit as the first major regular source of objective news not generated by the wellness industry’s propaganda apparatus.

June brought the RAND report, our Wall Street Journal op-ed, and Cracking Health Costs. Unlike Health Affairs, some HR administrators have actually read those publications. These developments left them asking uncomfortable questions of an industry that hitherto had filtered the information that its customers received through the JOEM and the Journal of Health Promotion, the industry’s de facto house organs that between them in thirty years have published fewer articles concluding wellness doesn’t work (just that single meta-analysis mentioned above) than Health Affairs has in 2013 alone.

But it wasn’t until July that the wheels fell off the wellness bus, due to four self-inflicted wounds that did more to diminish the industry’s carefully cultivated albeit totally undeserved patina than anything we could have written. Atoning for its brief foray into accuracy, JOEM published an article showing $20-million in savings for British Petroleum’s (BP) wellness program, 100 times what the vendor, Staywell, claims on its own website to be possible.

And by BP’s own admission only 1138 people stayed in the program long enough and were successful enough to reduce risk factors at all. (Not to mention that the 20,000 people in the program would not have even had incurred $20-million of wellness-sensitive medical claims in the first place, making avoidance of that much mathematically impossible.) Ironically, to prevent exactly this type of embarrassment, BP had retained Mercer to guard its henhouse by validating Staywell’s findings, but Mercer – which had a pre-existing relationship with Staywell — endorsed the findings instead. So rather than guard BP’s henhouse from Staywell, Mercer held a chicken barbeque in their honor.

Second, Limeade bravely broke ranks and acknowledged the obvious truth that no wellness company had hitherto admitted: Comparing participants to non-participants to show savings – the methodology upon which the industry’s entire pyramid of savings claims were built — is invalid. In Limeade’s eloquent words: “Self-improvers are likely to be drawn to self-improvement programs, and self-improvers are more likely to improve.”

They Can’t Handle the Truth

July’s third self-inflicted wound was the decision of the C. Everett Koop Wellness Award Committee to honor a program whose data was obviously made up…and then to refuse to rescind the award when the three perpetrators of those lies – a vendor that claims wellness programs don’t even have to exist to save money and the state of Nebraska – admitted the most egregious falsehood: the 514 people who they claimed had cancers on which they made “life-saving catches” did not in fact have cancer at all. Rather, they had lesions and polyps that had small chances of someday turning into cancer. To say Nebraska’s program made 514 “life-saving catches” would be only slightly more accurate than saying that getting 514 people to wear seat belts saves 514 lives. Indeed, the National Cancer Institute itself has now chimed in and said that it is critical to stop labeling noncancerous lesions as cancer because doing so promotes both fear and unnecessary care.

Even by the ethical standards of the wellness industry, where every single vendor claiming savings can easily be shown to be making them up, besmirching the name of history’s most revered Surgeon General for dishonest commercial purposes elevated malfeasance to a new plateau. Koop Committee members, allegedly the field’s leaders (representing Truven Health Analytics, along with Staywell and Mercer), asked themselves the question: “How would America’s Family Doctor — a man whose integrity was his calling card – have reacted to his name used to endorse acknowledged lies?” and decided his reaction wouldn’t matter. So they let their friends in Nebraska keep their award notwithstanding their lies.

The health services blogosphere was atwitter with outrage, and LinkedIn polls of the wellness rank-and-file were unanimous in opposition. It would also appear that the Koop Committee is taking a major gamble that the lay press won’t notice their desecration of perhaps the most popular and accomplished Surgeon General ever.

But Wait…There’s Less

July began with news from tech powerhouse Intel that it was jumping from the wellness ship. The company’s director of healthcare strategy asserted that their wellness experience was sufficient to show that it “wasn’t going to bend the [cost] trend.”

Just a week later came the fourth self-inflicted wound that may ultimately bleed the contemporary wellness industry to death, as its most respected supporter also abandoned ship. For three years the industry had been clinging to the single article in a respected journal supporting a wellness ROI, a 2010 Health Affairs paper by Harvard Professor Katharine Baicker entitled: “Workplace Wellness Programs Can Generate Savings.” While it’s almost impossible to find a subsequent pro-wellness article that does not cite this one, that’s apparently not enough for the editor-in-chief of a newsletter called The Art of Health Promotion, who wrote: “Because of the importance of this independent study…, it should be cited much more frequently.”

Quite the contrary, we suspect that it will be cited much less frequently: On July 23rd, Professor Baicker abruptly became wellness’s Emily Litella. Interviewed on NPR’s Marketplace, she delighted critics and shocked true believers with her candor. She boldly replaced her seminal and oft-cited (more than 20,000 times, according to Google) 3.27-to-1 ROI conclusion that (along with fictional Safeway results) had launched the ACA’s wellness provision with an admission that even with 30 years of wellness programs “it’s too early to tell” whether these programs work. Curiously, she suggested instead that CEOs continue to “experiment” on their employees, not exactly the rallying cry the industry was hoping for.

The Industry Should Take a Mulligan

Where does the industry go from here? The preferred route seems to be self-parody. At one conference, a presentation entitled: “Help Employees and Dependants [sic] Become Better Stewards of Their Own Health and Well-being” proposed that wellness programs could prevent industrial waste (but apparently not spelling mistakes). Next, a wellness vendor held a webinar on why critics’ wellness math is wrong. Ironically the webinar’s featured speaker believes that wellness can reduce costs by more than 100%. And another vendor, demonstrating the industry’s gravitas, recently appointed a Chief Happy Officer.

The clincher, however, was the faculty revolt against the coercive, ill-conceived, and expensive Penn State wellness program, a joint venture of Highmark, WebMD, and the unofficial leader of the true believers, Ron Goetzel. The revolt story broke on THCB and soon went national. This was in late August. A month later, following withering coverage in almost every major publication and near-unanimous faculty disapproval, Penn State’s administration caved and abandoned the program.

We hope history will record the Penn State debacle as the industry’s high-water mark for stupidity, and we are proposing a total re-boot to ensure nothing like this ever happens again. Start by acknowledging that science knows shockingly little about obesity’s causes or solutions, blood values are crude predictors of adverse medical events, and screens are a major and expensive contributor to overdiagnosis. Put it all together and Professor Baicker is right: you are experimenting on your employees…and neither the science nor the math presages a favorable outcome.

So why not try a wholly new approach to wellness and instead of doing questionable or even harmful things to employees, do things for them and with them? Or, put another way, instead of trying to force people to change against their will (and possibly against their genes), facilitate change for those who are ready and need a little help opening the door to healthier opportunities. Offer (but don’t require or involve incentive/penalties) fitness/exercise options and make them convenient. Subsidize healthy food in the cafeteria. Beautify your campus and stairwells to encourage people to walk. Commission art, signage, and murals that deliver positive health messages. Do any number of things that remove impediments to good health for those who desire it and make it attractive and safe for those who are skeptical or reticent. This is a totally new strategy for most companies: helping water to flow downstream is a more promising strategy than trying to force it to flow upstream.

Measurement and program selection should be quite easy. Recall Limeade’s observation and ask three questions:

Finally, it’s time for new de facto industry leadership. We look at companies like StickK, Allone, and Healthways, which have broken ranks and acknowledged the lack of integrity in this field, thus enhancing their own. Limeade earns a spot that pantheon as well, based on its aforementioned industry White Paper. The pursuit of health through conventional wellness has become an embarrassing charade, and it does nothing but detract from the nation’s most pressing health needs. Despite the industry’s affection for fantasy, fables, and falsehoods, the summer’s events show clearly that at the end of the day facts matter.

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness. An iconoclast to the core, he is the author of the Khanna On Health Blog. He is also the Wellness Editor-At-Large for THCB.

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I was plastered around the inverted deck of the simulator.“Imagine Which.” Kevlar floats!The physique armour was so confident that I was caught, inverted on the outdoor patio from the 9D5. Even worse, the rest of the gear I’d on was getting snagged on my way through my egress route. Cargo hooks, helo body, and seats turned out to be only one more factor to disentangle myself through prior to I could leave the actual simulation.I’m unsure just how long I’d already been keeping my personal breath. Activity and emotional state may seriously reduce your breath keeping period.Outside the actual trainer,… Read more »

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5 years ago

Guest

Al Lewis

Thank you for noting this. Screening is a nuanced exercise in statistics and yet somehow an industry has been put in charge of this that mostly doesn’t even realize you can’t reduce a number by more than 100%. And the heck of it is, I know probably fifteen people who brag about how their doctor spotted something that otherwise would have been missed and saved their lives. Probably 14 of those people were overdiagnosed…but try convincing them of that. It also goes against common sense to say “don’t be screened.” And yet it’s the right answer most of the time.

During the debate over ObamaCare, a few of us warned that mandated wellness and preventive care benefits written into the bill by lobbyists for primary care and wellness care providers would be a big waste of time and money.

My thoughts were driven by several articles that I can no longer cite, but some of the important ones, including a NYT article, were in this 7/17/2009 blog:

The super high premiums that will be charged on ACA state exchanges could be cut considerably by eliminating ObamaCare’s wellness and preventive care mandated benefits.

Good piece and good discussion.

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5 years ago

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Al Lewis

Good point. the Cracking Health Costs line that gets quoted back to me the most is, if you’re a general leading an army into battle, would you rather have troops with high morale or troops with low cholesterol?

The two overlap quite a bit but there are things you do for morale (like serve food people want to eat) that don’t suppot health, and as we learned at Penn State, there are things allegedly done for health that are very bad for morale.

Why are we so hung up on creating a culture of health, wellness or a healthy organizational culture? Seems to me this focus is too narrow. I think we should be using terms like creating a culture of employee well-being or creating a positive, supportive organizational culture. Shouldn’t our goal be employee engagement with work and the workplace? As we all know, employee well-being (not just health or wellness) drives engagement and health or wellness is only one aspect of well-being.

No one is “hung up” on a culture of health. More important is that we don’t get hung up on petty disputes over semantics, splitting hairs over words and phrases that are open to interpretation or may mean the same thing. The trend to make the distinction between wellness and wellbeing is simply an updated version of the old trend to distinguish between wellness and health. You can call it whole health, or wellness, or well-being, or yuzzamatuzz, and your employees really won’t care. But they know the difference between an environment that is energizing vs. one that is depleting.… Read more »

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5 years ago

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William McPeck

No argument from me Bob that our focus should be on culture and climate. Since words matter, I disagree that we shouldn’t address semantics. A good example I believe is participation vs. engagement. My observation is that folks equate health and wellness as being the same thing. As long as we continue to say “culture of health or wellness” I fear we will remain stuck or seen as continuing in the wellness cul-de-sac. I also agree that our focus should be the whole person, which is why I like and use well-being as it equates with the whole person and… Read more »

Hear, hear, Bill. I greatly appreciate your thoughtful comments, and your getting our dialog back to a grounded status that I risked veering us off of. I have the utmost respect for you and your work. I think there’s room in the conversation for everyone — employers, employees, vendors, consultants, and academicians. But I, personally, hold in the highest regard the opinions and experience of practitioners, such as yourself, who understand the real challenges of meeting the needs of complex organizations as well as the diverse needs of employee populations. Anyone with an internet connection can publicly criticize, but actually… Read more »

Yes–I interpreted that language as a face-saving way of backing out altogether, since once they pause long enough to read literature other than what Highmark’s consultant showed them (according to their HR VP Susan Basso, they haven’t read anything else, at least not yet), they’ll see they dodged a financial bullet.

However, if indeed at the end of the year they reinstate the penalties, let me know and I’ll reserve some front-page space in all the blogs I contribute to…

Actually, Penn State never had an employee wellness program; they had an employee surveillance program. Life insurance companies often require a medical exam prior to purchasing policies, but they don’t have the audacity to call it a wellness program. And even if they did, none of us would be naive enough to believe them. As someone who believes that, contrary to the consensus here, good employers with sufficient resources have an imperative to support the well-being of employees, I find it regrettable that both advocates and critics speak interchangeably about these desperate, heavy-handed, misguided attempts at cost containment and employee… Read more »

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5 years ago

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Mitch Collins

Maybe the Pennsylvania readers of this blog could write to their representatives and ask why PS is wasting money on a program that obviously does not work? Especially with the $50M+ and counting they are spending on the abuse scandal.

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5 years ago

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David Burrows

One correction: Penn State has not abandoned their wellness program – they have merely dropped penalties for noncompliance for this year.

Good summary review on what has been a questionable practice all along – HR driven wellness programs. In a research rpt we did a couple of yrs back we found a number of lg employers pretty ticked off at their HR depts for not effectively getting at the heart of the healthcare cost problem – the cost of care delivered – and instead, trying to slap bandaids (wellness programs, CDHP – cost shifting, etc.) on arterial wounds. I remember one very lg employer mentioning that things had gotten way out of hand with over 30 wellness vendors showing up for… Read more »

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5 years ago

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Mitch Collins

I think it is unfair to call wellness programs HR driven. HR is under pressure to “do something” about health care costs and at least the good ones know the real drivers that can impact this are the things that drive the organizational toxicity mentioned above. Now, if the CEO comes in and tells you to fix something and you inform her she needs to run the organization differently, stop making people work 90 hours a week and on and on…..you will be unemployed. So you “do something.” You were not told to do something that worked, just do something.… Read more »

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5 years ago

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Tom Emerick

Psychosocial toxicity is just what is happening in HR departments across the US.

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